PTSD: Post Traumatic Stress Disorder

The Symptomology of PTSD

PTSD is characterized by two dimensions of symptoms: intrusion - which includes nightmares, startle reaction, hyper-vigilance and insomnia - and avoidance - characterized by social withdrawal, low interest, poor concentration, and avoidance of past memories. According to James Boehnlein (1985) the avoidance symptomology appears to be resistant to change. There are also come culturally bound symptoms which do not fit into either of these symptom categories; for example, shame seems to be the culturally acceptable coping style of Cambodians who survived the Khmer Rouge killing fields.

Intensive emotional upset may be triggered by stimuli that symbolize the traumatic event, eg. anniversaries or relevant films/newscasts. In a study to determine the effect of such stimuli on mental processing, McNally et al (1990) did a study of the Stroop test with Vietnam war veterans diagnosed with PTSD and a control group. There was no significant between group difference in the time required to read the lists of words. However, when words were included which were related to the Vietnam War, the PTSD group experienced significantly higher levels of interference.

There is comorbidity with other disorders, particularly depression and substance abuse. PTSD patients also tend to experience marital problems, poor physical health, sexual dysfunction, and occupational impairment. Often they also exhibit stress-related psychophysical problems such as low back pain, headaches, and gastrointestinal disorders. Some children regress – losing already acquired developmental skills, eg. speech or toilet training (Davison, Neale, and Kring).

PTSD in survivors of ethnic cleansing may evolve with a different pattern of symptom clusters than it does in cases resulting from disasters or combat. Survivors of genocidal trauma do not have a few discrete traumatic memories that come and go; their lives are continuously inundated with traumatic images. One man said that he does not have “memories” of the war.  He insists that what he has are films of traumas that constantly play in his head (Weine, 1995). The chronic nature and universality of symptoms have differentiated concentration camp victims from others suffering from PTSD. Concentration camp victims’ symptoms often directly impeded their social adjustment and resulted in a passive, fatalistic personality, hopelessness, and a loss of previously enjoyed activities.

Research by Peter Suedfeld (2003) examined the attributional patterns in Holocaust survivors. Suedfeld argues that the trauma of genocide and state sponsored oppression creates a situation in which the explanatory constructs that once might have served under normal circumstances now became untenable. Janoff-Bulman (1992) refers to this as the shattering of the assumptive world. Suedfeld found that the attributional style of the Holocaust survivors tends to be much more external - ie. luck, God, fate. Interestingly, when asked why someone survived the Holocaust, survivors were more likely than a Jewish control group to mention help from others – including help from Gentiles, which was not mentioned by any members of the comparison group. Although help from others was prominently mentioned in the study, survivors nevertheless have low trust in others and a skeptical view of their benevolence

In Steven Weine's research on PTSD among Bosnian refugees in the USA, he found some interesting manifestations of symptomology. 65% of the refugees he interviewed met the DSM-IIIR criteria for PTSD and 35% for depression. Of subjects older than 18, all but one met diagnostic criteria for PTSD; none of the subjects less than 18 years old met criteria for PTSD. Correlational analysis indicated that older age was associated with higher PTD severity scores (r = 0.60; p<0.0001). He concluded that traumatic exposure in adolescents often does not take the form of adult PTSD, but is manifest in traumatic play, behavioural reenactments, and cognitive distortions. This makes a universal diagnostic strategy for PTSD improbable at best.

The Aetiology of PTSD

The following are the more traditional explanations of the aetiology of PTSD.

Learning theorists such as Orr, see PTSD as part of the continuum of phobic responses. Orr has argued that classical conditioning interacting with physiological responses can be used to explain the symptoms.

Psychodynamic theorists, such as Horowitz, argue that invasive memories are either consciously suppressed or repressed; The basis of the disorder is an internal struggle to integrate the trauma into the patient's existing beliefs about himself and the world.

There is also evidence that biology may play a role in PTSD. Evidence suggests that trauma may stimulate the noradrenergic system – raising norepinephrine levels (Davison, Neale, and Kring). A genetic predisposition also appears to be possible; PTSD is said to pass inter-generationally in societies (Hauff and Vaglum, 1994).

However, the vast number of studies today tend to focus on a more social-based approach. For example, current diagnostic literature suggests that experiences with racism and oppression are predisposing factors for PTSD. In his review of the literature, Roysircar (2000) cites research that among Vietnam War veterans 20.6% of Black and 27.6% of Hispanic veterans met the criteria for a current diagnosis of PTSD compared to 13% of whites (Kukla et al, 1990). In his research on PTSD in Rwandan children, Dyregrov goes a step further, arguing that threat of death was the factor that evidenced the strongest influence on intrusion and avoidance symptomology. This appears to have support in research in Bosnia, where in 1998 close to 73% of girls and 35% of boys in Sarajevo suffered from symptoms of PTSD; Kaminer, Seedat, Lockhart and Stein (2000) credited the higher rate of PTSD in girls to fear of rape.

The implications of the research in post-genocidal societies is significant. With the growing evidence that social factors may play a significant role in PTSD, Karen Hanscom argue that we need to expand the treatment model beyond the office and shift to community-oriented approaches.

The Treatment of PTSD

In this section, western methods of treatment are discussed. In the Bosnia section, Steven Weine's work with testimonial therapy will be discussed. In the section on cultural considerations, Karen Hanscom's work on community-based approaches will be discussed.

Until recently, majority of the therapy for PTSD has been based on a cognitive/behavioural or a psychodynamic approach. Often medication - anti-depressants and tranquilizers - is used to deal with conditions comorbid to PTSD which may impair therapy. Boehnlein (1985) found in his study of Cambodian refugees that tricyclics were helpful in treating the depression as well as the PTSD symptoms of nightmares, startle reactions and intrusive thoughts.  Benzodiazapines seemed ineffective. He also argued that traditional psychoanalysis had little effect in alleviating PTSD symptoms; he attributes these therapeutic failures to the difficulty of entering into a therapeutic alliance with these patients.

Edna Foa has proposed what she calls "exposure goals." She argues that there are four goals of cognitive behavioural therapy: 1. Create a safe environment that shows that the trauma cannot hurt them. 2. Show that remembering the trauma is not equivalent to experiencing it again. 3. Show that anxiety is alleviated over time. 4. Acknowledge that experiencing PTSD symptoms does not lead to a loss of control (Davison, Neale, and Kring). Though exposure therapy has yielded positive results, Keane (1992) has pointed out that patients may become initially worse in the initial stages of therapy, and therapists themselves may leave upset when they hear about the patient’s experiences. In addition, contrary to Foa's third goal, Dyregrov, Gjestad and Raundalen (1999) found that time alone did little to alleviate IES scores among Iraqi children and adolescents following the Gulf War. The IES is a rather reliable indicator of PTSD.

Shapiro has pioneered the use of EMDR - Eye Movement Desensitization and Reprocessing, which involves having the patient move his/her eyes in line with the directions of the therapist while remembering the traumatic event. It is still unclear as to why this appears to work for some patients. A thorough description of the treatment can be found here.

As a result of such traumatic events as school shootings, we have seen the development of a field of psychology called traumatology. With the increase in interest in this area of treatment, we have seen the development of the Critical Incident Stress Debriefing - more commonly known as crisis intervention. These are the teams of psychologists that arrive at the scene to help the survivors and witnesses of a traumatic event. It is based on the assumption that it is best to intervene with survivors 24 – 72 hours after the traumatic incident, before PTSD sets in. Its effectiveness, however, is open to debate. First, the majority of people who experience trauma never develop PTSD. It appears that PTSD manifests itself in approximately 25% of people exposed to trauma. In cases of rape and ethnic cleansing, the numbers are significantly higher. Mayou et al (2000) argues that crisis intervention may do more harm than good; Immediately following a disaster, people are best served by the social support usually available to them in their families and communities; the coercion to be treated by strangers, even if well-intentioned, is not helpful and may even be intrusive and harmful.